Multicenter, Prospective Cohort Study of Oesophageal Injuries and Related Clinical Outcomes (MUSOIC study).

OBJECTIVE: To identify prognostic factors associated with 90-day mortality in patients with oesophageal perforation (OP), and characterize the specific timeline from presentation to intervention, and its relation to mortality. BACKGROUND: OP is a rare gastro-intestinal surgical emergency with a high mortality rate. However, there is no updated evidence on its outcomes in the context of centralized esophago-gastric services; updated consensus guidelines; and novel non-surgical treatment strategies. METHODS: A multi-center, prospective cohort study involving eight high-volume esophago-gastric centers (January 2016 to December 2020) was undertaken. The primary outcome measure was 90-day mortality. Secondary measures included length of hospital and ICU stay, and complications requiring re-intervention or re-admission. Mortality model training was performed using random forest, support-vector machines, and logistic regression with and without elastic net regularisation. Chronological analysis was performed by examining each patient's journey timepoint with reference to symptom onset. RESULTS: The mortality rate for 369 patients included was 18.9%. Patients treated conservatively, endoscopically, surgically, or combined approaches had mortality rates of 24.1%, 23.7%, 8.7%, and 18.2%, respectively. The predictive variables for mortality were Charlson comorbidity index, haemoglobin count, leucocyte count, creatinine levels, cause of perforation, presence of cancer, hospital transfer, CT findings, whether a contrast swallow was performed, and intervention type. Stepwise interval model showed that time to diagnosis was the most significant contributor to mortality. CONCLUSIONS: Non-surgical strategies have better outcomes and may be preferred in selected cohorts to manage perforations. Outcomes can be significantly improved through better risk-stratification based on afore-mentioned modifiable risk factors.

Multimodal Prehabilitation During Neoadjuvant Therapy Prior to Esophagogastric Cancer Resection: Effect on Cardiopulmonary Exercise Test Performance, Muscle Mass and Quality of Life-A Pilot Randomized Clinical Trial.

BACKGROUND: Neoadjuvant therapy reduces fitness, muscle mass, and quality of life (QOL). For patients undergoing chemotherapy and surgery for esophagogastric cancer, maintenance of fitness is paramount. This study investigated the effect of exercise and psychological prehabilitation on anaerobic threshold (AT) at cardiopulmonary exercise testing (CPET). Secondary endpoints included peak oxygen uptake (peak VO2), skeletal muscle mass, QOL, and neoadjuvant therapy completion. METHODS: This parallel-arm randomized controlled trial assigned patients with locally advanced esophagogastric cancer to receive prehabilitation or usual care. The 15-week program comprised twice-weekly supervised exercises, thrice-weekly home exercises, and psychological coaching. CPET was performed at baseline, 2 weeks after neoadjuvant therapy, and 1 week preoperatively. Skeletal muscle cross-sectional area at L3 was analyzed on staging and restaging computed tomography. QOL questionnaires were completed at baseline, mid-neoadjuvant therapy, at restaging laparoscopy, and postoperatively at 2 weeks, 6 weeks and 6 months. RESULTS: Fifty-four participants were randomized (prehabilitation group, n = 26; control group, n = 28). No difference in AT between groups was observed post-neoadjuvant therapy. Prehabilitation resulted in an attenuated peak VO2 decline {-0.4 [95% confidence interval (CI) -0.8 to 0.1] vs. -2.5 [95% CI -2.8 to -2.2] mL/kg/min; p = 0.022}, less muscle loss [-11.6 (95% CI -14.2 to -9.0) vs. -15.6 (95% CI -18.7 to -15.4) cm2/m2; p = 0.049], and improved QOL. More prehabilitation patients completed neoadjuvant therapy at full dose [prehabilitation group, 18 (75%) vs. control group, 13 (46%); p = 0.036]. No adverse events were reported. CONCLUSIONS: This study has demonstrated some retention of cardiopulmonary fitness (peak VO2), muscle, and QOL in prehabilitation subjects. Further large-scale trials will help determine whether these promising findings translate into improved clinical and oncological outcomes. Trial Registration ClinicalTrials.gov NCT02950324.

Laparoscopic versus open subtotal gastrectomy for adenocarcinoma of the stomach in a Western population: peri-operative and 5-year oncological outcomes.

BACKGROUND: This study compares the peri-operative and long-term oncological outcomes for laparoscopic subtotal gastrectomy (LSG) versus open subtotal gastrectomy (OSG) for adenocarcinoma of the stomach in a Western population. METHODS: A retrospective, intention-to-treat analysis study was conducted for consecutive patients undergoing gastrectomy with curative intent for adenocarcinoma of the stomach between November 2006 and October 2016. Univariate analysis was used to compare peri-operative outcomes between LSG and OSG. Logistic regression with bootstrapping validation was used to identify independent risk factors for predicting 2-year overall survival. RESULTS: The final analysis included 79 patients. When comparing LSG (n = 30) to OSG (n = 49), there was no difference in the number of resected lymph nodes (36 (IQR 24.3-44) vs. 42 (IQR 28-59), p = 0.165), a reduction in intra-operative blood loss (150 ml (IQR 100-250) vs. 553 ml (IQR 338-1075), p < 0.001) and an increase incidence of post-operative bleeding (3 patients vs. 0, p = 0.024), respectively. Five-year overall survival for LSG (n = 22) versus OSG (n = 20) was 63.6% and 50% (p = 0.372), respectively. The number of positive lymph nodes [OR 0.64 (CI 0.47-0.88), p = 0.006] was the only significant independent risk factor for 2-year overall survival. Pre-operative ASA grading and operative approach did not influence survival outcomes at 2 years. CONCLUSION: This study suggests that LSG is comparable to OSG in Western patients with respect to oncological quality and peri-operative morbidity. Two-year overall survival is predicted by the number of positive lymph nodes and not the operative access employed for resection.

International consensus on a complications list after gastrectomy for cancer.

BACKGROUND: Perioperative complications can affect outcomes after gastrectomy for cancer, with high mortality and morbidity rates ranging between 10 and 40%. The absence of a standardized system for recording complications generates wide variation in evaluating their impacts on outcomes and hinders proposals of quality-improvement projects. The aim of this study was to provide a list of defined gastrectomy complications approved through international consensus. METHODS: The Gastrectomy Complications Consensus Group consists of 34 European gastric cancer experts who are members of the International Gastric Cancer Association. A group meeting established the work plan for study implementation through Delphi surveys. A consensus was reached regarding a set of standardized methods to define gastrectomy complications. RESULTS: A standardized list of 27 defined complications (grouped into 3 intraoperative, 14 postoperative general, and 10 postoperative surgical complications) was created to provide a simple but accurate template for recording individual gastrectomy complications. A consensus was reached for both the list of complications that should be considered major adverse events after gastrectomy for cancer and their specific definitions. The study group also agreed that an assessment of each surgical case should be completed at patient discharge and 90 days postoperatively using a Complication Recording Sheet. CONCLUSION: The list of defined complications (soon to be validated in an international multicenter study) and the ongoing development of an electronic datasheet app to record them provide the basic infrastructure to reach the ultimate goals of standardized international data collection, establishment of benchmark results, and fostering of quality-improvement projects.

Surgical resection of hepatic metastases from gastric cancer: outcomes from national series in England.

BACKGROUND: The objectives of this national study were to examine the short-term safety and long-term survival benefit associated with surgical resection of hepatic metastases from gastric cancer. METHODS: Patients from the Hospital Episode Statistics database were classified by disease and treatment approach. Gastric cancer: 1. Without liver metastases treated by gastrectomy (GG). 2. With liver metastases treated by gastrectomy and hepatectomy (GGH). 3. With liver metastases treated by gastrectomy without hepatectomy (GGNH). 4. With liver metastases treated with no surgery (GNS). Propensity score matching and multivariable analyses were used to compensate for differences in some baseline characteristics. RESULTS: During the study period, 87,482 were patients diagnosed with gastric cancer, of whom 13,841 underwent partial or total gastrectomy. Of those who underwent gastrectomy, 336 had a diagnosis of liver metastases and 78 of these had a hepatectomy. Propensity-matched analysis showed no significant differences in 30- or 90-day mortality between the GGH and GG groups. The GGH group had significantly improved 1-year mortality (35.9 % vs. 50.0 %, p = 0.049) and 5-year mortality (61.5 % vs. 75.7 %, p = 0.031) compared to the GGNH group, and compared to the GNS group, the GCH group had 1-year mortality (35.9 % vs. 84.6 %, p < 0.001) and 5-year mortality (61.5 % vs. 90.8 %, p < 0.001). CONCLUSIONS: This study showed that hepatectomy for synchronous gastric cancer hepatic metastases may carry survival benefits in selected patients. The data presented should not be a rationale to change current clinical practice but rather a stimulus to prospectively study the role of surgery in a selected group of patients who are currently treated with palliative chemotherapy.

Follow-up after gastrectomy for cancer: the Charter Scaligero Consensus Conference.

PURPOSE: Presently, there is no scientific evidence supporting a definite role for follow-up after gastrectomy for cancer, and clinical practices are quite different around the globe. The aim of this consensus conference was to present an ideal prototype of follow-up after gastrectomy for cancer, based on shared experiences and taking into account the need to rationalize the diagnostic course without losing the possibility of detecting local recurrence at a potentially curable stage. METHODS: On June 19-22, 2013 in Verona (Italy), during the 10th International Gastric Cancer Congress (IGCC) of the International Gastric Cancer Association, a consensus meeting was held, concluding a 6-month, Web-based, consensus conference entitled "Rationale of oncological follow-up after gastrectomy for cancer." RESULTS: Forty-eight experts, with a geographical distribution reflecting different health cultures worldwide, participated in the consensus conference, and 39 attended the consensus meeting. Six statements were finally approved, displayed in a plenary session and signed by the vast majority of the 10th IGCC participants. These statements are attached as an annex to the Charter Scaligero on Gastric Cancer. CONCLUSION: After gastrectomy for cancer, oncological follow-up should be offered to patients; it should be tailored to the stage of the disease, mainly based on cross-sectional imaging, and should be discontinued after 5 years.

The role of the laparoendoscopic single site totally extraperitoneal approach to inguinal hernia repairs: a review and meta-analysis of the literature.

BACKGROUND: Laparoendoscopic single site (LESS) surgery may have perceived benefits of reduced visible scarring compared to conventional laparoscopic (LAP) totally extraperitoneal (TEP) hernia repairs. We reviewed the literature to compare LESS TEP inguinal hernia repairs with LAP TEP repairs. METHODS: We searched electronic databases for research published between January 2008 and January 2012. RESULTS: A total of 13 studies reported on 325 patients. The duration of surgery was 40-98 minutes for unilateral hernia and 41-121 minutes for bilateral repairs. Three studies involving 287 patients compared LESS TEP (n = 128) with LAP TEP (n = 159). There were no significant differences in operative duration for unilateral hernias (p = 0.63) or bilateral repairs (p = 0.29), and there were no significant differences in hospital stay (p > 0.99), intraoperative complications (p = 0.82) or early recurrence rates (p = 0.82). There was a trend toward earlier return to activity in the LESS TEP group (p = 0.07). CONCLUSION: Laparoendoscopic single site surgery TEP hernia repair is a relatively new technique and appears to be safe and effective. Advantages, such as less visible scarring, mean patients may opt for LESS TEP over LAP TEP. Further studies with clear definitions of outcome measures and robust follow-up to assess patient satisfaction, return to normal daily activities and recurrence are needed to strengthen the evidence.

CONTEXTE: La chirurgie laparoendoscopique à orifice unique (LESS) a comme avantage perçu une réduction des cicatrices apparentes comparativement aux réparations laparoscopiques (LAP) classiques totalement extrapéritonéales (TEP) des hernies. Nous avons passé en revue la littérature afin de comparer les réparations des hernies inguinales par chirurgie LESS TEP et par LAP TEP. MÉTHODES: Nous avons interrogé les bases de données électroniques pour y recenser la recherche publiée entre janvier 2008 et janvier 2012. RÉSULTATS: En tout, 13 études ont porté sur 325 patients. La durée de la chirurgie a été de 40 à 98 minutes pour les réparations de hernies unilatérales et de 41 à 121 minutes pour les réparations de hernies bilatérales. Trois études regroupant 287 patients ont comparé la technique LESS TEP (n = 128) à la technique LAP TEP (n = 159). On n'a observé aucune différence significative quant à la durée de la chirurgie des réparations de hernies unilatérales (p = 0,63) ou bilatérales (p = 0,29) et aucune différence significative de durée des séjours hospitaliers (p > 0,99), de complications peropératoires (p = 0,82) ou de taux de récurrences précoces (p = 0,82). On a noté une tendance à un retour plus rapide aux activités dans le groupe soumis à la technique LESS TEP (p = 0,07). CONCLUSION: La réparation de hernie par chirurgie TEP laparoendoscopique à un seul orifice est une technique relativement nouvelle et semble sécuritaire et efficace. Ses avantages, par exemple des cicatrices moins apparentes, pourraient pousser les patients à opter pour la technique LESS TEP plutôt que LAP TEP. Il faudra procéder à d'autres études fondées sur des définitions paramétriques claires et comportant un suivi robuste pour évaluer la satisfaction des patients, la reprise des activités quotidiennes normales et les taux de récurrences afin de consolider les preuves.

Updates on surgical management of advanced gastric cancer: new evidence and trends. Insights from the First International Course on Upper Gastrointestinal Surgery--Varese (Italy), December 2, 2011.

Between the Ninth International Gastric Cancer Congress (IGCC) in South-Korea (Seoul, 2011) and the Tenth IGCC in Italy (Verona, 2013), the Insubria University organized the First International Course on Upper Gastrointestinal Surgery (Varese, December 2, 2011), with the patronage of Italian Research Group for Gastric Cancer (IRGGC) and the International Gastric Cancer Association (IGCA). The Course was intended to be a comprehensive update and review on advanced gastric cancer (GC) staging and treatment from well-known international experts. Clinical, research, and educational aspects of the surgeon's role in the era of stage-adapted therapy were discussed. As highlighted in the meeting, in this final document we summarize and thoroughly analyze (with references only for well-acquired randomized control trials) the new and old open problems in surgical management of advanced GC. Between the Ninth (Seoul, 2011) and the Tenth (Verona,2013) International Gastric Cancer Congress, the First International Course on Upper Gastrointestinal Surgery (Varese, December 2, 2011) was organized by the University of Insubria. This congress received the patronage of the International Gastric Cancer Association and the Italian Research Group for Gastric Cancer. The aim was to discuss open issues in surgical management of advanced gastric malignancies. We considered the opinions of several recognized experts in the field from both the Eastern and Western world, focused on definition problems and oncological and technical issues to define the current principles of advanced gastric cancer (GC) surgery.

Trimodality therapy versus perioperative chemotherapy in the management of locally advanced adenocarcinoma of the oesophagus and oesophagogastric junction (Neo-AEGIS): an open-label, randomised, phase 3 trial.

BACKGROUND: The optimum curative approach to adenocarcinoma of the oesophagus and oesophagogastric junction is unknown. We aimed to compare trimodality therapy (preoperative radiotherapy with carboplatin plus paclitaxel [CROSS regimen]) with optimum contemporaneous perioperative chemotherapy regimens (epirubicin plus cisplatin or oxaliplatin plus fluorouracil or capecitabine [a modified MAGIC regimen] before 2018 and fluorouracil, leucovorin, oxaliplatin, and docetaxel [FLOT] subsequently). METHODS: Neo-AEGIS (CTRIAL-IE 10-14) was an open-label, randomised, phase 3 trial done at 24 centres in Europe. Patients aged 18 years or older with clinical tumour stage T2-3, nodal stage N0-3, and M0 adenocarcinoma of the oesophagus and oesophagogastric junction were randomly assigned to perioperative chemotherapy (three preoperative and three postoperative 3-week cycles of intravenous 50 mg/m2 epirubicin on day 1 plus intravenous 60 mg/m2 cisplatin or intravenous 130 mg/m2 oxaliplatin on day 1 plus continuous infusion of 200 mg/m2 fluorouracil daily or oral 625 mg/m2 capecitabine twice daily up to 2018, with four preoperative and four postoperative 2-week cycles of 2600 mg/m2 fluorouracil, 85 mg/m2 oxaliplatin, 200 mg/m2 leucovorin, and 50 mg/m2 docetaxel intravenously on day 1 as an option from 2018) or trimodality therapy (41·4 Gy in 23 fractions on days 1-5, 8-12, 15-19, 22-26, and 29-31 with intravenous area under the curve 2 mg/mL per min carboplatin plus intravenous 50 mg/m2 paclitaxel on days 1, 8, 15, 22, and 29). The primary endpoint was overall survival, assessed in all randomly assigned patients who received at least one dose of study drug, regardless of which study drug they received, by intention to treat. Secondary endpoints were disease-free survival, site of treatment failure, operative complications, toxicity, pathological response (complete [ypT0N0] and major [tumour regression grade 1 and 2]), margin-free resection (R0), and health-related quality of life. Toxicity and safety data were analysed in the safety population, defined as patients who took at least one dose of study drug, according to treatment actually received. The initial power calculation was based on superiority of trimodality therapy (n=366 patients); it was adjusted after FLOT became an option to a non-inferiority design with a margin of 5% for perioperative chemotherapy (n=540). This study is registered with ClinicalTrials.gov, NCT01726452. FINDINGS: Between Jan 24, 2013, and Dec 23, 2020, 377 patients were randomly assigned, of whom 362 were included in the intention-to treat population (327 [90%] male and 360 [99%] White): 184 in the perioperative chemotherapy group and 178 in the trimodality therapy group. The trial closed prematurely in December, 2020, after the second interim futility analysis (143 deaths), on the basis of similar survival metrics and the impact of the COVID-19 pandemic. At a median follow-up of 38·8 months (IQR 16·3-55·1), median overall survival was 48·0 months (95% CI 33·6-64·8) in the perioperative chemotherapy group and 49·2 months (34·8-74·4) in the trimodality therapy group (3-year overall survival 55% [95% CI 47-62] vs 57% [49-64]; hazard ratio 1·03 [95% CI 0·77-1·38]; log-rank p=0·82). Median disease-free survival was 32·4 months (95% CI 22·8-64·8) in the perioperative chemotherapy group and 24·0 months (18·0-40·8) in the trimodality therapy group [hazard ratio 0·89 [95% CI 0·68-1·17]; log-rank p=0·41). The pattern of recurrence, locoregional or systemic, was not significantly different (odds ratio 1·35 [95% CI 0·63-2·91], p=0·44). Pathological complete response (odds ratio 0·33 [95% CI 0·14-0·81], p=0·012), major pathological response (0·21 [0·12-0·38], p<0·0001), and R0 rates (0·21 [0·08-0·53], p=0·0003) favoured trimodality therapy. The most common grade 3-4 adverse event was neutropenia (49 [27%] of 183 patients in the perioperative chemotherapy group vs 11 [6%] of 178 patients in the trimodality therapy group), followed by diarrhoea (20 [11%] vs none), and pulmonary embolism (ten [5%] vs nine [5%]). One (1%) patient in the perioperative chemotherapy group and three (2%) patients in the trimodality therapy group died from serious adverse events, two (one in each group) of which were possibly related to treatment. No differences were seen in operative mortality (five [3%] deaths in the perioperative chemotherapy group vs four [2%] in the trimodality therapy group), major morbidity, or in global health status at 1 and 3 years. INTERPRETATION: Although underpowered and incomplete, Neo-AEGIS provides the largest comprehensive randomised dataset for patients with adenocarcinoma of the oesophagus and oesophagogastric junction treated with perioperative chemotherapy (predominantly the modified MAGIC regimen), and CROSS trimodality therapy, and reports similar 3-year survival and no major differences in operative and health-related quality of life outcomes. We suggest that these data support continued clinical equipoise. FUNDING: Health Research Board, Cancer Research UK, Irish Cancer Society, Oesophageal Cancer Fund, and French National Cancer Institute.

Two-phase laparoscopic-assisted oesophago-gastrectomy: a single-unit experience of 111 consecutive cases and outcomes.

BACKGROUND: Minimal access surgery for oesophago-gastric cancer is topical and demanding, and approaches vary significantly. There is little data on the hybrid technique of laparoscopic-assisted two-phase oesophago-gastrectomy (LA2OG). Here we aim to review our experience, which exceeds 10 years, of this technique for oesophageal malignancy. METHODS: From June 1998 to May 2009, 111 patients underwent LA2OG. Patients included 84 men and 27 women with mean age 65 years (range 35-85 years). Retrospective analysis of indications, outcome, staging, complications and survival was performed. RESULTS: The majority of resections (96%) were performed for gastro-oesophageal junction or distal oesophageal pathology. Indications included adenocarcinoma (84.7%), squamous cell carcinoma (7.2%) and high-grade dysplasia (5.4%). Of patients, 67.6% received neoadjuvant chemotherapy. The median time for the laparoscopic phase was 207 min (range 105-600 min), and 420 min (range 210-780 min) overall. Estimated blood loss was 330 ml (range 100-1,200 ml). Median critical care and post-operative stays were 3 and 14 days, respectively. Over time, the radicality of surgery increased. From 1998 to 2001 median lymph node yield was 5, from 2002 to 2005 it was 12 nodes, and from 2006 to 2009 it was 28 nodes (p < 0.001). The overall complication rate was 38.7%, minor in 24.3%, with anastomotic leak rate of 5.5%. Median survival was 38.5 ± 5.4 months. Thirty-day and in-hospital mortality were 1.8 and 2.7%, respectively. CONCLUSIONS: Two-stage laparoscopic-assisted oesophago-gastrectomy is a safe staged method of developing minimal access surgery for oesophago-gastric cancer. This study provides a useful reference for comparison with other minimally invasive methods.

Sarcomatoid Carcinoma Arising in a Gastric Duplication Cyst.

Malignancy arising within a gastric duplication cyst (GDC) is extremely rare; only 15 cases have been reported in the literature. We present a 70-year-old woman who was referred with a history of vague postprandial abdominal discomfort. Subsequent imaging identified a gastric cystic mass. A laparoscopic sleeve gastrectomy of a 90 × 60 × 60-mm cystic mass was performed. Histopathological examination showed the presence of a sarcomatoid carcinoma arising within a GDC. The patient, unfortunately, died 5 months after surgery with metastatic disease. To the best of our knowledge, this is the first case of sarcomatoid carcinoma arising within a GDC.

A randomised controlled trial to assess whether prehabilitation improves fitness in patients undergoing neoadjuvant treatment prior to oesophagogastric cancer surgery: study protocol.

INTRODUCTION: Neoadjuvant therapy prior to oesophagogastric resection is the gold standard of care for patients with T2 and/or nodal disease. Despite this, studies have taught us that chemotherapy decreases patients' functional capacity as assessed by cardiopulmonary exercise (CPX) testing. We aim to show that a multimodal prehabilitation programme, comprising supervised exercise, psychological coaching and nutritional support, will physically, psychologically and metabolically optimise these patients prior to oesophagogastric cancer surgery so they may better withstand the immense physical and metabolic stress placed on them by radical curative major surgery. METHODS AND ANALYSIS: This will be a prospective, randomised, controlled, parallel, single-centre superiority trial comparing a multimodal 'prehabilitation' intervention with 'standard care' in patients with oesophagogastric malignancy who are treated with neoadjuvant therapy prior to surgical resection. The primary aim is to demonstrate an improvement in baseline cardiopulmonary function as assessed by anaerobic threshold during CPX testing in an interventional (prehab) group following a 15-week preoperative exercise programme, throughout and following neoadjuvant treatment, when compared with those that undergo standard care (control group). Secondary objectives include changes in peak oxygen uptake and work rate (total watts achieved) at CPX testing, insulin resistance, quality of life, chemotherapy-related toxicity and completion, nutritional assessment, postoperative complication rate, length of stay and overall mortality. ETHICS AND DISSEMINATION: This study has been approved by the London-Bromley Research Ethics Committee and registered on ClinicalTrials.gov. The results will be disseminated in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT02950324; Pre-results.

Lichen planus in the oesophagus: are we missing something?

Lichen planus of the oesophagus is rare with a predilection for middle-aged to elderly women. There is a potential risk of malignant transformation to squamous cell carcinoma. Squamous cell carcinoma of the oesophagus still accounts for 30-40% of oesophageal cancer cases in the west and is almost exclusively the disease still encountered in the rest of the world. An increased awareness of oesophageal lichen planus is suggested in patients with cutaneous, oral or vulval disease. Endoscopic investigation of patients with lichen planus, possibly initially limited to those with oesophageal symptoms, and consideration of surveillance in patients with proven oesophageal lichen planus, will aid understanding of natural history of lesions and may help detect early stage tumours. Squamous cell carcinoma still accounts for 30-40% of oesophageal cancer cases in the west and is almost exclusively the disease still encountered elsewhere. Lichen planus of the oesophagus is potentially a premalignant condition for squamous cell carcinoma that could be surveilled in order to detect early-stage tumours with a consequent greater chance of cure. Oesophageal lichen planus is, however, rare, frequently asymptomatic and although the majority of cases occur in conjunction with lichen planus in other sites, the oesophageal features may be subtle and easily missed by endoscopic assessment. Furthermore, the histological changes are difficult to interpret and there may be significant underreporting. As a consequence, the true prevalence of these lesions is hard to determine. The difficulties in detection may mean that we are underestimating the frequency of oesophageal lichen planus. Endoscopic detection may be aided by the use of magnification indigo carmine chromoendoscopy and this warrants further evaluation. The risk of malignant transformation is currently unknown but may parallel that of oral lesions at approximately 1-3%. An increased awareness of the condition can only help to identify more cases and increase our understanding of this interesting condition.

Surgical treatments for esophageal cancers.

The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on the role of the nurse in preparation of esophageal resection (ER); the management of patients who develop high-grade dysplasia after having undergone Nissen fundoplication; the trajectory of care for the patient with esophageal cancer; the influence of the site of tumor in the choice of treatment; the best location for esophagogastrostomy; management of chylous leak after esophagectomy; the optimal approach to manage thoracic esophageal leak after esophagectomy; the choice for operational approach in surgery of cardioesophageal crossing; the advantages of robot esophagectomy; the place of open esophagectomy; the advantages of esophagectomy compared to definitive chemoradiotherapy; the pathologist report in the resected specimen; the best way to manage patients with unsuspected positive microscopic margin after ER; enhanced recovery after surgery for ER: expedited care protocols; and long-term quality of life in patients following esophagectomy.

Thoracoscopic-assisted four-phase esophagectomy with four-field lymph node dissection for esophageal cancer: case report and description of a new technique.

Complete (R0) resection and extent of lymphadenectomy are important prognostic factors for survival in patients undergoing surgery for esophageal carcinoma. We describe the first case of combined open and thoracoscopic esophagectomy with extended lymphadenectomy including abdominal, cervical, right, and left mediastinal (four-field, four-phase) nodal clearance in a 37-year-old woman with squamous cell carcinoma of the esophagus. This report provides a tailored strategy to achieve a high level of tumor clearance and complete resection. The approach described challenges the limitations of standard radical nodal clearance and may encourage surgeons to consider more extensive resections.

A literature review on the role of totally extraperitoneal repairs for groin pain in athletes.

A literature review was made on the role of totally extraperitoneal (TEP) hernia repairs for groin pain in athletes. Electronic databases were searched for literature published from January 1993 to November 2011. There were 10 articles incorporating 196 patients included in this review. Thirty percent of patients were reported to have direct inguinal hernias, 22% had indirect inguinal hernias, and 41% had dilated internal rings. Of note, 30% of cases had no macroscopic abnormality. Four studies reported on an early follow-up ranging between 3 and 6 weeks. Only minimal or mild symptoms were reported. Up to 33% of patients had impaired ability to perform at peak levels. Up to 53% of patients had persistence of symptoms at the early follow-up. Total follow-up time ranged from 3 to 80 months, and most patients were active (90%-100%). At long-term follow-up, 3% to 10% were unable to play, and 5% were reported as being unable to train. Two studies from the same center reported on TEP surgery for osteitis pubis, and most patients returned to sporting activity after 4 to 8 weeks. TEP repair is a good operative intervention in athletes with chronic groin pain not relieved by conservative measures. Athletes recover quickly and return to sport early.